CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 1
INTRODUCTION:
Expertise in the management of “medical complications of pregnancy” (otherwise
known as Obstetric Medicine) is an expectation for trainees completing residency training in Internal Medicine in Canada, as outlined in the Objectives of Training and Specialty Training
Requirements in Internal Medicine of the Royal College of Physicians and Surgeons of Canada. This objective is meant to be achieved despite the lack of a formal or standardized
national framework for training in obstetric medicine, along with infrequent and regionally variable clinical experience in caring for pregnant women with medical disorders. The great
majority of Internal Medicine residents will not have received any systematic instruction about the assessment and management of medical problems in pregnancy, thereby failing to
link the curriculum to certification requirements and health care needs, as advocated by experts in curriculum design. A recent survey of Canadian graduates of General Internal
Medicine residencies confirmed that obstetric medicine is one of the areas within the CanMEDS competencies which showed the greatest perceived gap between importance
(high) and preparation (low) among new specialist physicians (Card et al., 2006). In response to similar concerns in other countries, the International Society of Obstetric Medicine
(ISOM) recently began a process to: outline the body of knowledge in Internal Medicine of particular relevance to pregnancy, identify specific conditions unique to pregnancy, and to
define the context in which training in this knowledge should occur.
Recognizing the abundance of talented obstetric medicine physicians in Canada, as well as the unique scope of practice of training and in General Internal Medicine in this
country, a national curriculum validation project was undertaken to synthesize a comprehensive Obstetric Medicine Curriculum for training of specialty residents in Canada.
This document is the product of that process.
This Canadian Obstetric Medicine Curriculum is a summary of the attitudes, abilities and knowledge which should be imparted to Canadian Internal Medicine trainees in the
domain of Obstetric Medicine. The information is organized in three sections: general principles, competencies specific to each organ system and tabular data. The competencies
are presented in CanMeds format. The curriculum document may serve as a blueprint for the creation of curricular objectives, may guide the selection of appropriate instructional
strategies, and may stimulate the development of valid alternative educational strategies (ie. for rare conditions) and assessment methods. It may also assist in defining the context in
which training should occur, and serve as a model for local curricula adapted to the level of the trainees involved.
Toronto, April 24th, 2010
Annabelle Cumyn, M.D., MHPE Paul S. Gibson, M.D.
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 2
CanCOM Obstetric Medicine Curriculum
This table describes the competencies required to practice Obstetric Medicine. The
content of this curriculum blueprint is based on several sources including the
curriculum endorsed by the International Society of Obstetric Medicine, validated by subject-matter experts across Canada, and adapted to reflect the educational
standards of the Royal College of Physicians and Surgeons of Canada.
SECTION 1: GENERAL PRINCIPLES
1. CanMEDS COMPETENCIES FOR OBSTETRIC MEDICINE
1.0 Medical Expert
Medical expert is the central role and refers to the application of medical knowledge, clinical and professional skills. This role will be developed for each discipline under section 2.
1.1 Communicator
1.1.1 CONCEPTS:
Establishes effective rapport, trust and ethical therapeutic relationships with:
Patient and family
Multidisciplinary team and allied health professionals
Accurately obtains, synthesizes and conveys relevant data from:
Patient, family, colleagues and other professionals
Develops a common understanding on issues, problems and plans with:
Patient, family and multidisciplinary team
Provides accurate and sensitive information:
During preconception counseling of women with chronic medical disorders
On risk:benefit profile of medication use in pregnancy and breastfeeding
On risk:benefit of various diagnostic and therapeutic options in pregnancy
On the need to discuss the reliability of information obtained from the internet
1.2 Collaborator
1.2.1 CONCEPTS
Consults effectively with inter-professional healthcare team
Understands and respects the role of each healthcare provider
Contributes effectively to other interdisciplinary activities and meetings
Facilitates care and coordination of follow-up during the pregnancy and post-partum
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 3
1.3 Manager
1.3.1 CONCEPTS:
Organizes investigations within an acceptable time frame, taking into consideration the availability of resources
Works efficiently within a health care organization
1.4 Health advocate
1.4.1 CONCEPTS:
Provides accurate and sensitive counseling on:
Impact of smoking, alcohol, and recreational drugs on health of mother and fetus
Tools available in pregnancy for a healthier lifestyle
Psychological impact of a complicated pregnancy on mother and family
Promotes preventive health care in the setting of preconception care, pregnancy and the post-partum
Responds to the individual patient’s and community health needs
1.5 Scholar
1.5.1 CONCEPTS:
Seeks and critically appraises medical information to answer clinical questions
Facilitates learning of patients, families, and other health professionals
Demonstrates leadership in the development of appropriate protocols for care, when possible
Consults available resources for medication risk-benefit profile in pregnancy and lactation
1.6 Professional
1.6.1 CONCEPTS:
Demonstrates commitment to patients and profession through an ethical practice
Recognizes the predominant ethical dilemmas in Obstetric Medicine
Delivers quality care with integrity and compassion
Recognizes limitation in knowledge and skills, and appropriately consults another health professional in:
Caring for patients with rare or complex medical conditions (for example: cancer, transplant, obstetric complications)
2. PHYSIOLOGY OF PREGNANCY
2.1 Cardiovascular changes
2.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of pregnancy on blood volume, vascular resistance, and cardiac output
Impact of normal hemodynamic changes on symptomatology , physical findings and laboratory parameters (table I)
Hemodynamic changes associated with labor, delivery, and the postpartum period
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 4
2.2 Respiratory physiology
2.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of pregnancy on respiratory rate, lung volumes and normal symptomatology
Impact of pregnancy on sleep quality, architecture, and time
2.3 Renal physiology
2.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of the increase in renal blood flow on kidney size and function (table I)
Changes in renal collecting system due to hormonal and mechanical factors
Impact of pregnancy on renal tubular function and findings on urinalysis
Impact of placental vasopressinase on ADH metabolism
2.4 Metabolic changes
2.4.1 CONCEPTS:
Demonstrates applied knowledge of the:
Normal metabolic and endocrine changes associated with pregnancy
Impact of placental hormones on maternal glucose and lipid metabolism
Relative insulin resistance and hypercorticolism associated with pregnancy
3. PHARMACOLOGY OF PREGNANCY AND LACTATION
3.1 General principles
3.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Background risks of congenital anomalies, spontaneous abortion, and fetal complications
Etiologies related to congenital anomalies
Notion of critical period for anomalies specific to each organ system
Importance of antenatal counseling to reduce risk of congenital anomalies
Impact of pregnancy of drug pharmacodynamics
Factors that affect drug transfer into breast milk
Drugs that influence milk supply
Importance of an evidence-based approach when communicating risks and benefits of a pharmacotherapeutic agent with a patient
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 5
4. DIAGNOSTIC AND THERAPEUTIC RADIATION IN PREGNANCY
4.1 Diagnostic imaging
4.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Potential impact of fetal radiation exposure according to timing during pregnancy
Expected fetal radiation exposure associated with common radiological examinations (refer to table II)
Approach to imaging with intravenous contrast agents or radiopharmaceuticals during breastfeeding
4.2.Therapeutic radiation
4.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Risk:benefit of radiation therapy during each trimester of pregnancy
5. ACUTE CARE AND MATERNAL RESUSCITATION
5.1 Acute respiratory failure
5.1.1 CONCEPTS:
Demonstrates understanding of:
Expected changes in blood gas parameters associated with pregnancy
Impact of pregnancy and medications on risk of pulmonary edema
5.1.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Impact of pregnancy on approach to intubation
Risk of mucosal friability associated with nasal intubation
Appropriate investigation and treatment of the pregnant patient with acute shortness of breath
Target pO2 and pCO2 in the intubated pregnant patient
Indications for ICU consultation and assisted ventilation
5.1.3 COMPLICATIONS:
Demonstrates applied knowledge of the:
Risk of maternal complications associated with inadequate ventilator parameters
Impact of position, hypovolemia and alkalosis on uteroplacental flow
5.2 Cardiopulmonary resuscitation
5.2.1 CONCEPTS:
Demonstrates applied knowledge of:
The impact of pregnancy on mucosal friability and chest compliance
The impact of aortocaval compression on venous return and effectiveness of resuscitation efforts
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 6
5.2.2 MANAGEMENT:
Demonstrates applied knowledge of:
ACLS in pregnancy including left lateral displacement of the uterus, early intubation, use and placement of adhesive pads for defibrillation, and removal of fetal monitor to avoid electrical arcing
The role of caesarian delivery after 4 minutes of unsuccessful resuscitation for cardiac arrest in a patient at 20-24 weeks gestation or more
The coordination of care in the ICU setting and the importance of glycemic control and thromboprophylaxis
6. SURGICAL AND ANAESTHETIC CONSIDERATIONS
6.2 General principals
6.2.1 CONCEPTS:
Demonstrates understanding of the:
Most common indications for surgery and ideal timing for surgical intervention in pregnancy
Impact of pregnancy on presentation of acute abdomen
Variety of anaesthetic approaches and impact on maternal physiology
Maternal and fetal risks associated with various surgical and anesthetic procedures in pregnancy
Impact of the pregnancy on risk of hypoxemia, aspiration and intubation
6.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Indications for thrombotic and antibiotic prophylaxis
Specific maternal and fetal considerations such as volume replacement, positioning, and monitoring
7. RELEVANT OBSTETRIC AND GYNECOLOGIC CONDITIONS
7.1 Septic pelvic vein thrombosis
7.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Typical presentation, risk factors, and types of septic thrombosis
Associated risk of pulmonary embolism or regional extension
7.1.2 EVALUATION:
Demonstrates applied knowledge of the:
Approaches to diagnosis
7.1.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Therapeutic modalities
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 7
7.2 Amniotic fluid embolism
7.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Major clinical findings in AFE
Hemodynamic alterations associated with AFE
7.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Supportive measures taken to correct hypoxemia and hypotension
7.3 Endometritis
7.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Prevalence and risk factors for endometritis in the postpartum period
Differential diagnosis of fever in the postpartum
Prevalence of polymicrobial infection with sexually transmitted infections
7.3.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Usual approach to treatment
7.3.3 COMPLICATIONS:
Possibility of lethal toxic-shock syndrome associated with rare Clostridial infections
7.4 Postpartum hemorrhage
7.4.1 CONCEPTS:
Demonstrates an understanding of:
Most common causes of early and delayed PPH
7.4.2 EVALUATION:
Demonstrates applied knowledge of the:
Circumstances in which medical etiologies or contributing factors should be sought
7.4.3 MANAGEMENT:
Demonstrates an understanding of the:
Sequence of non-operative and operative interventions for the treatment of PPH
7.5 Assisted reproduction technology (ART)
7.5.1 CONCEPTS:
Demonstrates an understanding of the:
Variety of options available to patients with fertility problems
Obstetrical and medical complications associated with ART
Risk factors and classification of ovarian hyperstimulation syndrome (OHSS)
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 8
7.5.2 MANAGEMENT:
Demonstrates an understanding of the:
Indications for thromboprophylaxis in OHSS
Treatment modalities for OHSS
7.5.3 COMPLICATIONS:
Demonstrates an understanding of the:
Complications associated with ART and grade III OHSS
SECTION 2: SPECIFIC DISORDERS
8.HYPERTENSIVE DISORDERS
8.1. Chronic hypertension
8.1.1 EVALUATION:
Demonstrates applied knowledge of the:
Baseline investigations to be done prior to or at the onset of pregnancy in a woman with hypertension
Work-up of secondary causes of hypertension as it pertains to pregnancy
Physiologic changes to BP in pregnancy
Associated conditions that may alter BP targets, and related complications
Demonstrates skills in the:
Appropriate approach to BP measurement in the pregnant woman
8.1.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Current national guidelines on the management of hypertensive disorders in pregnancy
Safety profile of antihypertensive medications during pregnancy and breastfeeding
Approach to BP control and indications for drug therapy
Appropriate antenatal and post-partum follow-up of hypertensive women
Strategies to reduce the risk of preeclampsia
Laboratory investigations for diagnosis of preeclampsia
Demonstrates appreciation of the:
Role played by uteroplacental doppler ultrasound in obstetrical management
8.1.3 COMPLICATIONS:
Demonstrates competency in:
Counseling mothers regarding the risk of maternal complications
Demonstrates understanding of the:
Fetal complications associated with maternal chronic hypertension
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 9
Accurately educates the mother on the:
Symptoms and signs of preeclampsia
8.2 Gestational hypertension / Preeclampsia
8.2.1 EVALUATION:
Demonstrates applied knowledge of the:
Definitions based on latest Canadian consensus guidelines
Pathophysiology of preeclampsia
Risk factors that place women at a higher risk of preeclampsia
Definition of significant proteinuria in pregnancy
Differential diagnosis of atypical preeclampsia
8.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Appropriate investigations and follow-up of women with suspected preeclampsia
Maternal indications for therapy and hospitalization
Appropriate recognition and management of severe hypertension
Adequate management of peripartum fluid balance
Appropriately collaborates in the:
Multidiscliplinary discussion around optimal timing for delivery
8.2.3 COMPLICATIONS:
Demonstrates applied knowledge in the:
Appropriate recognition and management of associated major maternal complications including HELLP syndrome, DIC, acute renal failure, hypertensive encephalopathy, pulmonary edema, eclampsia and other related medical emergencies
Develops an understanding of the:
Indications for MgSO4 use in the prevention and treatment of eclampsia
8.2.4 POSTPARTUM MANAGEMENT:
Demonstrates applied knowledge of the:
Post-partum evolution of BP in preeclampsia
Natural evolution and appropriate follow-up of laboratory abnormalities postpartum
Indications for investigation of thrombotic predisposition
Provides accurate and sensitive counseling on the:
Risk of recurrence of preeclampsia in future pregnancies
Association between placental disorders and increased risk of long-term metabolic, renal and cardiovascular disease
Strategies including lifestyle modifications and regular follow-up to reduce risk of metabolic and cardiovascular disease
Seeks and critically evaluates data on the:
Prevention of preeclampsia in subsequent pregnancies
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 10
9. CARDIOLOGY
9.1 Evaluation of palpitations, presyncope and syncope
9.1.1 EVALUATION:
Demonstrates skills in the:
Performance of a physical examination of the cardiovascular system of the pregnant woman
Demonstrates applied knowledge of the:
Appropriate evaluation and investigations for palpitations, presyncope and syncope
9.1.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Appropriate treatment of the most prevalent arrhythmias in pregnancy (symptomatic sinus tachycardia, SVT, AF, and atrial flutter)
Presence of an increased risk of arrhythmia, pulmonary edema, hypotension during labour
Demonstrates appreciation of the:
Importance of educating mothers on the normal cardiovascular symptoms in pregnancy
9.2 Acquired and Congenital Heart Disease
9.2.1 CONCEPTS:
Demonstrates an understanding of the:
Impact of pregnancy associated hemodynamic changes on different types of congenital and acquired pathologies
Impact of cardiac disease on pregnancy outcome
Features associated with a higher maternal risk
Increased risk of fetal cardiac malformations with family history of cardiac malformations
Various approaches to anticoagulation for prosthetic cardiac valves during pregnancy, labour, and the postpartum
Period of highest risk for warfarin teratogenicity
9.2.2. MANAGEMENT:
Demonstrates applied knowledge of the:
Role of folic acid for woman with a personal or family history of congenital cardiac anomaly
History, physical examination, and investigations to detect deterioration in cardiac function
Usefulness of a variety of maternal monitoring devices during labour and post-partum period
Management of maternal cardiac complications
Indications for endocarditis prophylaxis
9.3 Cardiomyopathies
9.3.1 EVALUATION
Demonstrates understanding of the:
Risk factors associated with an peripartum cardiomyopathy (PPCM)
Diagnostic features of peripartum cardiomyopathy
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 11
Demonstrates applied knowledge of the:
Differential diagnosis of pulmonary edema in pregnancy
Risk of maternal and fetal complications of acute and chronic heart failure
9.3.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Investigations for the evaluation of heart failure
Cardiac medications acceptable for use in pregnancy
Treatment of congestive heart failure in pregnancy
Demonstrates understanding of the:
Impact of cardiac disease on delivery plan
Role of prophylactic anticoagulation in women with a depression LVEF
Possible pathogenic role of prolactin in PPCM
9.3.3 COMPLICATIONS:
Demonstrates appreciation of the:
Risk of recurrence of peripartum cardiomyopathy or deterioration of cardiac function in subsequent pregnancies
Approaches to evaluate and counsel women on the risk of cardiac complications in subsequent pregnancies
10. ENDOCRINOLOGY
10.1 Pregestational diabetes
10.1.1 EVALUATION:
Demonstrates applied knowledge of the:
Preconception and baseline evaluation of glycemic control, medication use, and history of severe complications
Adjustment of medications in preparation for pregnancy
Preconception target in HbA1C and impact on risk of miscarriages and fetal malformations
Evaluation of target organ damage at baseline and during the course of pregnancy
Evaluation of comorbidities associated with type 1 and 2 diabetes
Importance of preconceptional folic acid use at an appropriate dose
Provides accurate and sensitive counseling on the:
Risk of maternal complications such as hypoglycemic and hyperglycemic episodes, DKA, progressive retinopathy and nephropathy, preeclampsia
10.1.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Treatment modalities in pregnancy and targets for glycemic control
Expected changes in insulin requirements during the course of pregnancy, following steroid administration and the early post-partum period
Management of diabetes during labor and the postpartum period
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 12
10.1.3 COMPLICATIONS:
Demonstrates applied knowledge of the:
Management of maternal complications
Demonstrates understanding of the:
Impact of poor glycemic control on fetus, neonate and longer term risk of metabolic disease
Possible impact of valsalva maneuvers during delivery on severe retinopathy
10.2 Gestational diabetes
10.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Pathophysiology of insulin resistance in pregnancy
Risk factors for gestational diabetes
Demonstrates appreciation of the:
Contribution of cultural and religious background to diet and lifestyle habits
10.2.2 SCREENING:
Demonstrates applied knowledge of the:
Canadian Diabetes Association guidelines for impaired glucose tolerance and gestational diabetes
Demonstrates understanding of the:
Indications for early screening, usual screening and repeat screening
Optimal timing for screening for high risk populations
10.2.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Baseline assessment at time of diagnosis of GDM
Contribution of a consultation with dietitian and exercise therapist
Nature of follow-up and targets for glycemic control
Non-pharmacological approach to glycemic control
Indications to start pharmacological therapy
Risks and benefits of selected medications
Recommendations for postpartum follow-up
10.2.4 COMPLICATIONS:
Demonstrates applied knowledge of the:
Associated risk of gestational hypertension
Long-term risk of type 2 DM
Risk of occurrence in subsequent pregnancies
Demonstrates understanding of the:
Obstetric and delivery complications associated with untreated gestational diabetes
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 13
Counsels on the:
Lifelong risk of obesity, diabetes and other adverse maternal outcomes
Importance of early screening before and during a next pregnancy
Promotes health by explaining:
Required lifestyle changes and optimal follow-up of other cardiovascular risk markers
10.3 Obesity and metabolic syndrome
10.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of obesity on insulin resistance, oxygen demand, and cardiac work
Associated risk of aspiration, sleep disorders, and restrictive lung disease
Appropriate pre-conception counseling
Demonstrates accurate and sensitive counseling on:
Appropriate nutrition and weight gain during pregnancy
10.3.2 EVALUATION:
Demonstrates applied knowledge of the:
Importance of early screening for GDM
Approach to the patient with prior bariatric surgery according to type of intervention
10.3.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Appropriate follow-up for placental-mediated disorders and other complications
10.3.4 COMPLICATIONS:
Demonstrates applied knowledge of the:
Risk of adverse fetal and maternal outcomes during pregnancy and delivery
10.4 Thyroid disorders
10.4.1 CONCEPTS:
Demonstrates applied knowledge of the:
Normal variations of TSH and T4 levels in pregnancy
Differential diagnosis of hypothyroidism in pregnancy
Differential diagnosis of hyperthyroidism in pregnancy
Impact of pregnancy on Grave’s disease
Link between abnormal thyroid results, hyperemesis gravidarum, and molar pregnancy
Interaction between iron, calcium and levo-thyroxine absorption
Provides accurate and sensitive counseling on the:
Possible association between inadequately treated hypothyroidism and cognitive deficits in the newborn
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 14
10.4.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Possible need for increased thyroid replacement therapy at onset and during pregnancy
Appropriate follow-up of TSH, T4 and goals of therapy
Treatment choices for hyperthyroidism in pregnancy and breastfeeding
Options for follow-up and adjustment of thyroid replacement therapy after delivery
10.4.3 COMPLICATIONS:
Demonstrates understanding of the:
Link between thyroid disorders and obstetrical complications
Benefits of treating subclinical and frank hypothyroidism on maternal and fetal outcomes
Demonstrates applied knowledge of the:
Recognition and management of post-partum thyroiditis
Recognition and management of thyroid storm in pregnancy and the peripartum period
Demonstrates understanding of the:
Options for fetal surveillance when maternal TSI antibodies present in high titer
10.5 Pituitary disorders
10.5.1 CONCEPTS:
Demonstrates applied knowledge of the:
Return of fertility after treatment of prolactinomas
Impact of pregnancy on prolactinoma size
Variability in presentation of Sheehan syndrome in the post-partum period
Importance of considering mild hypopituitarism in women with difficulty lactating
10.5.2 EVALUATION:
Demonstrates applied knowledge of the:
Possibility of hypopituitarism in the patient with severe post-partum hemorrhage and ongoing hypotension
10.5.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Management of prolactinoma during pregnancy, the preconception period and during lactation
10.5.4 COMPLICATIONS:
Demonstrates applied knowledge of the:
Clinical presentation of an increase in prolactinoma size
Typical presentation of pituitary apoplexy
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 15
10.6 Adrenal disorders
10.6.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of pregnancy on clinical presentation of Cushing’s syndrome
10.6.2 EVALUATION:
Demonstrates applied knowledge of the:
Approach to diagnosis of Cushing’s syndrome in pregnancy
10.6.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Therapeutic options for the treatment of Cushing’s syndrome in pregnancy
Indications for stress dose steroids at the time of delivery
10.6.4 COMPLICATIONS:
Demonstrates applied knowledge of the:
High rate of complications associated with untreated Cushing’s syndrome in pregnancy
10.7 Diabetes insipidus
10.7.1 CONCEPTS:
Demonstrates applied knowledge of the:
Changes in ADH physiology in pregnancy
Typical presentation of gestational DI
Different etiologies and associations of DI in pregnancy
10.7.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Therapeutic options for DI in pregnancy
11. HEMATOLOGY
11.1 Anemia
11.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of anemia in pregnancy
11.1.2 EVALUATION:
Demonstrates applied knowledge of the:
Diagnostic value of serum ferritin
11.1.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Treatment of iron-deficiency in pregnancy and indications for parenteral iron therapy
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 16
11.2 Thromboembolic disorders
11.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Thromboembolic predisposition associated with pregnancy and the early post-partum period
Additional factors which increase risk of venous thromboembolism
Mortality associated with thromboembolic disorders
Interpretation of d-dimers in pregnancy
11.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Appropriate investigations for VTE
Management of VTE in pregnancy, labour, and the post-partum period
Approaches for monitoring laboratory markers of anticoagulation
Demonstrates understanding of the:
Indications for thromboprophylaxis in pregnancy and the post-partum period
Impact of anticoagulation on anaesthetic and obstetric management at the time of delivery
11.2.3 COMPLICATIONS
Demonstrates applied knowledge of the:
Maternal and fetal complications associated with anticoagulation therapy
11.3 Thrombophilias
11.3.1 CONCEPTS:
Demonstrates understanding of the:
Additional hypercoagulable states and their respective thrombotic risk
Impact of pregnancy on laboratory results of components of the coagulation cascade
Seeks and critically evaluates data on:
Thrombophilic predispositions and obstetrical complications
11.3.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Implications of thrombophilic predisposition on management during pregnancy and the post-partum period
Different heparin regimen and their respective indications
11.4 Thrombocytopenia
11.4.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of thrombocytopenia in pregnancy
11.4.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Risk of bleeding associated with various levels of thrombocytopenia
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 17
Treatment of ITP in pregnancy
Demonstrates understanding of the:
Risk of fetal thrombocytopenia associated with maternal ITP
Demonstrates effective collaboration with:
Obstetrics and Anaesthesia to plan mode of delivery and regional anesthesia and analgesic choices
11.5 Bleeding disorders
11.5.1 CONCEPTS:
Demonstrates applied knowledge of:
When investigate with a personal or familial bleeding history
Impact of pregnancy on VWD
11.5.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Management of VWD in pregnancy and the peripartum period
Indications for transfusion therapy
Management of consumptive coagulopathies
Accurate counsels on the:
Risks associated with various blood products
11.6 Hemoglobinopathies
11.6.1 CONCEPTS:
Demonstrates applied knowledge of the:
Complications associated with sickle cell anemia in pregnancy
Differential diagnosis of a low MCV
Demonstrates appreciation of the:
Importance of offering families with hemoglobinopathies a consultation with medical genetics
11.6.2 EVALUATION:
Demonstrates understanding of the:
Preconception evaluation of the patient with an hemoglobinopathy
11.6.3 MANAGEMENT:
Demonstrates understanding of the:
Management of sickle cell patients in pregnancy
Acute care of the pregnant patient with a sickle cell crisis or acute chest syndrome
Demonstrates appreciation of the:
Importance of multidisciplinary care for patients with sickle cell anemia
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 18
12. RESPIROLOGY
12.1 General principles
12.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of acute shortness of breath in pregnancy, labour and the post-partum period
Appropriate evaluation of respiratory symptoms in pregnancy
Increased prevalence of obstructive sleep apnea in pregnancy
Demonstrates appreciation of the:
Impact of physiological changes on exercise tolerance
12.2 Asthma
12.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Factors which increase risk of asthmatic exacerbation
Impact of asthmatic exacerbation on pregnancy outcome
12.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Adequate control of asthma in pregnancy and breastfeeding
Management of other frequent causes of respiratory complaints in pregnancy such as allergic and gestational rhinitis
Promotes health by educating on the:
Importance of developing a self-management plan
Importance of compliance and of early self-referral for persistent asthmatic symptoms
12.3 Cystic fibrosis
12.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of disease severity on adverse maternal outcomes
Demonstrates understanding of the:
Importance of genetic counseling
12.3.2 EVALUATION:
Demonstrates applied knowledge of the:
Importance of optimal, stable pulmonary function prior to conception
12.3.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Importance of multidisciplinary care including close follow-up of maternal nutrition and weight gain
Importance of early screening for gestational diabetes
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 19
13. NEPHROLOGY
13.1 Physiological changes
13.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of physiologic changes in morphology
Normal proteinuria, albuminuria and serum creatinine in pregnancy (Table I)
Risk factors for nephrolithiasis and pyelonephritis
13.2 Acute renal failure
13.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of acute renal failure (ARF) in pregnancy
13.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Evaluation and management of ARF in pregnancy
Importance of avoiding nephrotoxic medications and considering drug adjustments
13.2.3 COMPLICATIONS:
Demonstrates applied knowledge of the:
Increased risk of acute tubular necrosis in the context of hypovolemia, preeclampsia and bleeding
13.3 Chronic renal failure
13.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of renal dysfunction on maternal and fetal outcomes
Impact of pregnancy on renal dysfunction
Role of prenatal creatinine clearance in preconception counseling
Risks associated with ACE inhibitors and ARBs in pregnancy
Demonstrates appreciation of the:
Importance of prenatal counseling for women with chronic renal failure (CRF)
Modifications to hemodialysis regimens in pregnancy
Role of genetic counseling in inherited renal disorders
13.3.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Impact of renal disease on target for BP control
Adequate follow-up of renal function in pregnancy
13.3.3 COMPLICATIONS:
Demonstrates applied knowledge of the:
Factors associated with a risk of progression to end stage renal failure
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 20
14.TRANSPLANT MEDICINE
14.1 General principles
14.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Maternal and fetal risks associated with anti-rejection medications and pregnancy
Ideal time delay between transplant and pregnancy
Importance of reviewing vaccination history
14.1.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Investigations prior to conception and during pregnancy
Importance of early recognition of rejection
Management of infectious complications such as CMV reactivation
15. GASTROENTOROLOGY
15.1 Hyperemesis gravidarum
15.1.1 EVALUATION:
Demonstrates applied knowledge of the:
Differential diagnosis of nausea in pregnancy
Biochemical anomalies associated with HG
Risk factors for severe HG
Demonstrates appreciation of the:
Psychosocial consequences of HG
15.1.2 MANAGEMENT:
Demonstrates understanding of the:
Indications for hospitalization
Therapeutic approaches including risk and benefits of hyperalimentation
Demonstrates appreciation of the:
Value of a multidisciplinary approach with experts in high-risk pregnancy, pharmacy, psychology, social work, and nutrition
15.1.3 COMPLICATIONS
Demonstrates applied knowledge of the:
Maternal and fetal complications associated with severe HG
15.2 Dyspepsia
15.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Effects of pregnancy on gastrointestinal physiology
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 21
Differential diagnosis of dyspepsia in pregnancy
Demonstrates appreciation of the:
Impact of dyspepsia during the pregnancy
15.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Risk and benefit profile of available non pharmacological and pharmacological treatment modalities
Indications and risks of gastroscopy in pregnancy
15.3 Hepatitis and liver dysfunction in pregnancy
15.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of abnormal liver enzymes and liver function tests in pregnancy
Impact of pregnancy on prevalence of cholestasis, cholelithiasis, and cholecystitis
Demonstrates understanding of the:
Impact of obstetric cholestasis on maternal and fetal pregnancy outcomes
Morbidity and mortality of acute fatty liver of pregnancy (AFLP)
Association of AFLP with DI and cross-over with preeclampsia and HELLP syndrome
15.3.2 EVALUATION:
Demonstrates applied knowledge of the:
Evaluation of abnormal liver enzymes and liver function tests in pregnancy
Demonstrates understanding of the:
Characteristic presentation of AFLP
15.3.3 MANAGEMENT:
Demonstrates applied knowledge of:
Therapeutic approaches to obstetric cholestasis (OC)
Demonstrates understanding of the:
Role of fetal surveillance in OC and optimal timing for delivery
Management of viral hepatitis in pregnancy
Management of AFLP
Role of LCHAD testing for counseling on risk of recurrence
15.3.4 COMPLICATIONS:
Demonstrates understanding of the:
Maternal and fetal complications associated with maternal hepatitis, cholestasis or hepatic dysfunction
Risk factors associated with fulminant hepatitis in pregnancy
Magnitude of perinatal transmission associated with the different viral hepatitides
Role of active and passive immunization to decrease vertical transmission of hepatitis B
Risk of severe hepatic failure in AFLP and indications for hepatic transplant
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 22
15.4 Cirrhosis
15.4.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of pregnancy on liver function and portal hypertension
Impact of chronic liver disease on pregnancy
15.4.2 EVALUATION:
Demonstrates applied knowledge of the:
Contribution from upper endoscopy in antenatal counseling
15.4.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Indications for beta-blocker prophylaxis against variceal hemorrhage
15.5 Inflammatory bowel disease
15.5.1 CONCEPTS:
Demonstrates applied knowledge of the:
Importance of stabilizing disease prior to conception
Usual course during pregnancy and the postpartum period
Maternal and fetal complications of IBD exacerbation during pregnancy
Demonstrates appreciation of:
Importance of prenatal counseling of patients with IBD
15.5.2 EVALUATION:
Demonstrates applied knowledge of the:
Importance to evaluate the presence of extra-intestinal manifestations of IBD
Risk and benefits of endoscopy in pregnancy
15.5.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Therapeutic approaches to IBD during pregnancy and the post-partum period
Appropriate assessment and management of patients with symptoms of exacerbation
Demonstrates appreciation of the:
Importance of nutritional counseling
15.5.4 COMPLICATIONS
Demonstrates applied knowledge of the:
Management of complications during pregnancy
Potential for malabsorption of fat soluble vitamins if distal ileal resection
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 23
16. NEUROLOGY
16.1 Headaches
16.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of headache in pregnancy
Natural history of headaches in pregnancy and the post-partum period
Prevalence of post-epidural headaches
Demonstrates appreciation of the:
Impact of headaches on quality of life in pregnancy
16.1.2 EVALUATION:
Demonstrates applied knowledge of the:
Evaluation of headache in pregnancy
Indications for imaging
16.1.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Non pharmacological management of benign chronic headaches
Safety profile of analgesics and other pharmacologic agents in pregnancy
Management of post-epidural headaches
16.2 Seizures
16.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of seizures in pregnancy
Factors which modify the risk of seizures in women with epilepsy
Importance of preconception counseling
Impact of antiepilectic drugs on folic acid metabolism
Factors which increase the teratogenic potential of anticonvulsivants
Demonstrates understanding of the:
Increased risk of epilepsy in children born to mothers or fathers with epilepsy
Accurately counsels patients on the:
Impact of seizures and medications on maternal and fetal pregnancy outcomes
16.2.2 MANAGEMENT:
Demonstrates applied knowledge in:
Pharmacological and non pharmacological approaches to decrease risk of seizures
Approaches to drug monitoring
Management of acute seizures in pregnancy
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 24
Demonstrates understanding of the:
Importance of counseling women regarding the transmission of antiepilectic medications in breast milk, contraception, and safe approaches when caring for neonate
16.2.3 COMPLICATIONS:
Demonstrates applied knowledge of the:
Increased risk of drug toxicity in first months postpartum
16.3 Cerebrovascular disease
16.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Risk factors for stroke in pregnancy
Differential diagnosis of hemorrhagic and ischemic stroke in pregnancy
Clinical presentations of hypertensive encephalopathy and reversible posterior leukoencephalopathy syndrome
16.3.2 EVALUATION:
Demonstrates applied knowledge of the:
Diagnostic evaluation of cerebrovascular symptoms in pregnancy
16.3.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Approach to patient with a history of prior stroke
Approach to patient with stroke in pregnancy and the post-partum period
16.4 Nerve compression syndromes
16.4.1 CONCEPTS:
Demonstrates applied knowledge of the:
Risk factors for nerve compression and entrapment syndromes in pregnancy
Time course for symptom resolution in the post-partum period
Increased prevalence of Bell’s palsy in pregnancy
Impact of pregnancy on outcome of Bell’s palsy
16.4.2 EVALUATION:
Demonstrates applied knowledge of the:
Typical presentation of carpal tunnel syndrome (CTS), sciatica and meralgia paraesthetica
16.4.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Available therapeutic modalities to diminish CTS and sciatica symptoms in pregnancy
Indications for treatment of Bell’s palsy and available medications in pregnancy
16.4.4 COMPLICATIONS:
Demonstrates applied knowledge of the:
Possible association of Bell’s palsy with pre-eclampsia
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 25
16.5 Myasthenia gravis
16.5.1 CONCEPTS:
Demonstrates applied knowledge of the:
Factors associated with the highest risk for MG exacerbation
Demonstrates an understanding of the:
Impact of MG on fetus development and risk of neonatal MG
Impact of MG on second stage of labour and the importance of planned multidisciplinary care
16.5.2 EVALUATION:
Demonstrates applied knowledge of the:
Baseline evaluation of pregnant patients with MG
16.5.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Necessity to treat infections promptly
Possible for dose adjustment of acetylcholinesterase inhibitors in pregnancy
16.5.4 COMPLICATIONS:
Demonstrates applied knowledge of the:
Initial symptoms associated with a myasthenic crisis
Relative contraindication for use of MGSO4 in this patient population
First line therapy for antihypertensive treatment in pregnant patients with MG
16.6 Multiple sclerosis
16.6.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of pregnancy on MS
Impact of MS on pregnancy
Factors which may increase risk of relapse in the post-partum period
16.6.2 MANAGEMENT:
Demonstrates understanding of the:
Management of acute attacks in pregnancy
17. INFECTIOUS DISEASES
17.1 Infections in general
17.1.1 CONCEPTS:
Demonstrates understanding of the:
Pathogens associated with an increased risk of obstetric complications (TORCH)
Pathogens associated with an increased risk of maternal morbidity and mortality
Most common causes of sepsis in pregnancy
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 26
17.2.1 MANAGEMENT:
Demonstrates applied knowledge of the:
Evaluation and management of the febrile pregnant woman
Management of various antibiotics and antivirals in pregnancy
17.2 Urinary tract infections
17.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Factors which increase the risk of urinary tract infections in pregnancy
Predominant causative organisms
17.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Most commonly used antibiotic regimens for lower and upper urinary tract infections
Indications for prophylactic regimens
Importance of cultures post treatment to confirm resolution
17.2.3 COMPLICATIONS:
Demonstrates applied knowledge of the:
Complication associated with untreated asymptomatic bacteriuria
Maternal complications associated with pyelonephritis
17.3 Respiratory infections
17.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of cough in pregnancy
Importance of measuring oxygen saturation in woman with suspected pneumonia
Morbidity and mortality associated with viral pneumonias in pregnancy
17.3.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Evaluation and management of respiratory infections in pregnancy
17.3.3 COMPLICATIONS:
Demonstrates applied knowledge of the:
Impact of pregnancy on the risk of a complicated pneumonia
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 27
17.4 Tuberculosis
17.4.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of pregnancy on risk of latent TB reactivation and course of active disease
17.4.2 EVALUATION:
Demonstrates applied knowledge of the:
Indications for testing of latent tuberculosis in pregnancy
17.4.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Approach to patient with positive tuberculin skin test in pregnancy
Agents to avoid when treating active tuberculosis
17.5 Human immunodeficiency virus
17.5.1 CONCEPTS:
Demonstrates understanding of the:
Risk of vertical transmission to fetus during pregnancy , delivery, and the postpartum period
Impact of HAART on the risk of vertical transmission
Safety profile and principal side-effects of antiretrovirals
Importance of interdisciplinary management with auxiliary care (social work, dietician, pharmacist
Provides accurate and sensitive counseling on the:
Risk of HIV transmission during breastfeeding
17.6 Immunizations
17.6.1 CONCEPTS:
Demonstrates applied knowledge of the:
Guidelines for immunization prior to pregnancy, in pregnancy, and in the post-partum period
Importance of addressing vaccination gaps
Effectiveness of immunization in pregnancy
Types of vaccines and safety profile in pregnancy
18. IMMUNOLOGIC DISORDERS
18.1 Systemic lupus erythematosus
18.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Impact of SLE on adverse maternal and fetal outcomes
Impact of pregnancy of disease markers
Factors which increase the risk of adverse pregnancy outcomes
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 28
Demonstrates appreciation of the:
Importance of prenatal counseling on factors which decrease risk of flare-up during pregnancy
18.1.2 EVALUATION:
Demonstrates applied knowledge of the:
Baseline assessment of function and disease markers
Importance of regular clinical and laboratory follow-up
Evaluation of proteinuria and renal dysfunction in these women
18.1.3 MANAGEMENT:
Demonstrates applied knowledge of the:
Therapeutic options for disease control
Impact of early treatment of exacerbations
Risk of exacerbation when discontinuing antimalarials
18.1.4 COMPLICATIONS:
Demonstrates applied knowledge of the:
Manifestations of other complications of SLE in pregnancy
Demonstrates understanding of the:
Fetal surveillance associated with the presence of anti-SSA and anti-SSB antibodies
18.2 Antiphospholipid syndrome
18.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Diagnostic criteria for APLS
Impact of APLS on adverse maternal and fetal outcomes
Association with other autoimmune disorders
18.2.2 EVALUATION
Demonstrates applied knowledge of the:
Impact of inter laboratory variations on diagnosis
Indications for testing and follow-up
18.2.3 MANAGEMENT
Demonstrates applied knowledge of the:
Therapeutic approaches in pregnancy
Demonstrates understanding of the:
Clinical features of catastrophic antiphoslipid syndrome
Provides accurate and relevant counseling on the:
Possibility of developing non-obstetrical manifestations in the future
18.3 Rheumatoid arthritis
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 29
18.3.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of symmetrical and asymmetrical arthritis in pregnancy and the postpartum period
Impact of pregnancy on RA disease activity
Safety profile of RA medications in pregnancy and lactation
Provides accurate counseling on the:
Risk of post-partum exacerbation
18.3.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Therapeutic approaches in pregnancy and the postpartum period
Available data regarding biologic agents
19. NEOPLASTIC DISORDERS
19.2 General principles
19.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Most common types of pregnancy-associated cancers
Impact of pregnancy on the interpretation of cytological specimens
Risk of transplacental metastases
Importance of pre-conception counseling including cardiac evaluation in patients with history of thoracic radiation or anthracyclin therapy
19.2.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Spectrum of therapeutic options in pregnancy and impact on mother and fetus
Impact of delaying delivery after chemotherapy for fetal bone marrow recovery
20. DERMATOLOGY
20.1 Dermatoses related to pregnancy
20.1.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of pruritus in pregnancy
Differential diagnosis of skin lesions in pregnancy
Usual presentation of PUPPP
Demonstrates appreciation of the:
Impact of pruritus on quality of sleep and quality of life
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 30
20.1.2 MANAGEMENT:
Demonstrates applied knowledge of the:
Therapeutic modalities for the relief of pruritus
Evaluation and management of bullous lesions in pregnancy
20.1.3 COMPLICATIONS:
Demonstrates applied knowledge of the:
Risk of neonatal complications in herpes gestationis
Risk of recurrence of herpes gestationis in future pregnancies or when taking oral contraceptive agents
21. Psychiatric illness
21.1 Chronic psychiatric conditions
21.1.1 CONCEPTS:
Demonstrates understanding of the:
Importance of preconception counseling in women with a history of chronic psychiatric conditions
Demonstrates accurate and empathetic counseling on:
The effect of pregnancy on pre-existing psychiatric illness
The risk benefits of psychiatric medication during pregnancy
Demonstrates appreciation of:
The role of multidisciplinary care with specialists with an expertise in mood disorders
21.1.2 MANAGEMENT:
Demonstrates applied knowledge of the:
How and when to screen for sexual, psychological, and physical abuse
When to contact local psychiatric services
21.2 Acute psychiatric conditions
21.2.1 CONCEPTS:
Demonstrates applied knowledge of the:
Differential diagnosis of psychosis in pregnancy
Risk factors for development of postnatal depression and puerperal psychosis
21.2.2 MANAGEMENT:
Demonstrates understanding of the:
Assessment and treatment of the pregnant patient with psychiatric symptoms
Importance of evaluating for medical or substance abuse comorbidities
Importance of involving psychiatric specialists and family in care of patient
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 31
21.2.3 COMPLICATIONS:
Demonstrates appreciation of the:
Importance of assessing actual suicidal and homicidal risk
21.3 Substance abuse disorders
21.3.1 CONCEPTS:
Demonstrates understanding of the:
Importance of addressing the possibility of substance abuse objectively and openly with patients
Impact of smoking on the pregnancy and fetus
Legal implications of substance abuse
21.3.2 MANAGEMENT:
Demonstrates competence and empathy in:
Discussing safety of different smoking cessation techniques in pregnancy
Counseling women about the impact of substance abuse on the pregnancy
Importance of referral to a substance abuse disorder clinic
Demonstrates applied knowledge of the:
Management of acute intoxication and withdrawal in pregnancy
Importance of screening for HIV and hepatitis C when relevant
Importance of multi-disciplinary care including anaesthesia and neonatology
21.3.3 COMPLICATIONS:
Demonstrations applied knowledge in the:
Evaluation of symptoms of withdrawal or intoxication
SECTION 3: TABLES
TABLE I: Impact of pregnancy on physical examination, normal laboratory values, and radiological findings
DISCIPLINE NORMAL FINDINGS IN PREGNANCY COMMENTS
Physical exam Decrease in BP by 12th week gestation with return to
normal by term
Mean BP decreases
by 10-15 mm Hg
Increase in heart rate by 10-20 beats/min with full brisk bounding pulses
An increase of 10-20%
Decrease in systemic vascular resistance Decreased by 25-30%
Midsystolic ejection flow murmur Increased volume in outflow tracts
Two physiologic continuous functional murmurs
(mammary and suprasternal hum)
Jugular venous distension Increased
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 32
intravascular volume
Lower extremity edema Increased intravascular volume,
IVC compression, decreased oncotic
pressure +/- changes in capillary
permeability
Increased respiratory rate from increased minute ventilation
Related to increased drive, basal metabolic
rate, and oxygen consumption
Pulmonary bibasilar rales that open on deep
inspiration
Occasionally in late
pregnancy
No significant change in pulmonary artery pressure
or pulmonary capillary wedge pressure
Haematology Hemoglobin: 100-130 g/L Physiologic anemia
Hematocrit Decreased because plasma volume
expansion is greater than increased
erythrocyte mass
Leucocyte count: 10-15 X 109/L Increased
Platelet count: 115-150 X 109/L in 10% pregnancies Nadir near term
Coagulation INR Unchanged
PTT Unchanged
Fibrinogen: superior to 2.0 g/L Increased
plasminogen activator inhibitors
D-dimers: less than 300 ug/L Increased
vWF factor: group O: 0.40-1.75 U/mL non group O: 0.70-2.10 u/mL
Increased
Factor VIII: 0.6-1.95 U/L Other coagulation
factors (V, VII, X) also increased by 20-
100% by term)
Protein C: 0.70-1.20 U/mL (antigen) Usually unchanged
Protein S: 0.57-1.20 U/mL (antigen) Decreased
Antithrombin III: 0.80-1.25 U/mL Unchanged
Homocysteine: less than 10 umol/L Decreased
Renal Creatinine: 35-44 mmol/L Decreased
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 33
Urea Decreased
Sodium: 133-135 meq/L 5 meq/L decrease
Potassium Unchanged
Bicarbonate: 18-22meq/L Decreased
pH: 7.40-7.45 Respiratory alkalosis
Uric acid Decreased
Plasma osmolality: 270 mosmol/lg
24 hour urine protein: up to 300mg 2 fold increase
Creatinine clearance: 120-160ml/min 2 fold increase by T2
Renin/angiotensin level 20-40% increase
Hepatic AST Unchanged
ALT Unchanged
Total bilirubin Unchanged
GGT Lower in second and
third trimester
Alkaline phosphatase: increased From placental origin
Albumine: 30-32mg/L 10-20% decrease in oncotic pressure
Endocrine TSH: 0.03-2.5 in T1; 0.03-3.0 in T2; 0.03-3.5 in T3 Values may vary according to
laboratory assay
Free T4: levels may be decreased in second half of pregnancy depending on assay used (analog method
less reliable than equilibrium dialysis method)
Difficult to measure reliably in setting of
elevated TBG
T3 Unchanged
Prolactin Increased up to 10
times normal
GH Increased from placental production
ACTH Increased from
placental production of CRH
Cortisol Increased
Aldosterone 4-6 fold increase by T3
Angiotensin II Increased
ADH Decreased from increased circulating
vasopressinase
Cathecholamines No change
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 34
Metabolic Fasting glucose: mean of 4.2 Decreased from active placental
transport
Triglycerides: 2.37 mmol/L 3 fold increase
Total cholesterol: 6.5 mmol/L 1.5 fold increase
LDL: 3.8 mmol/L 1.5 fold increase
HDL: 1.7 mmol/L 1.2 fold increase
VLDL: 0.65 mmol/L 2.5 fold increase
ABG and
pulmonary function tests
PaO2 increased to 100-105 Hg at sea level Probably from
increased cardiac output; can decrease
in supine position
Increased alveolar-arterial gradient to 20 In late stages of
pregnancy
Mild respiratory alkalosis with decreased PaCO2 to 28-32 mm Hg
From increased minute ventilation
HCO3 decreased to 20-21 Compensatory
increase in renal excretion
pH: 7.40-7.45 Compensated respiratory alkalosis
Lung volume subdivisions show an increase in tidal volume and a decrease in expiratory reserve volume
and residual volume
Decreased FRC with little change in
inspiratory capacity
Decreased lung compliance From decreased chest wall compliance
Spirometry is largely unchanged
CXR Increased pulmonary vascular markings Common
Cardiac silhouette suggestive of cardiomegaly From heart rotation and hypervolemia
Straightened left upper cardiac border with more horizontal heart position
Small pleural effusion In post-partum period in particular
EKG 15-20 degree left shift of axis From elevation of diaphragm
Periods of SVT and ESV Occasional
Q wave in lead III; minor ST-segment depression; T inversion in inferior and lateral leads
From changes in chest dimensions and
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 35
diaphragm position
Cardiac
ultrasound
Physiologic multivalvular regurgitation Predominantly right-
sided
Chamber enlargement (5-15% increase in chamber
size)
Resulting from a 30-
50% increase in blood volume
Small asymptomatic pericardial effusion Occasionally found in
T3; resolve by 6 weeks postpartum
Increase in cardiac output of 30-60% (5-7 L/min/m2)
Combined increase in preload, heart rate
and stroke volume
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 36
TABLE II: Mean Radiation Exposure to fetus associated with common imaging
procedures. Adapted with permission from Table 8-2: Robert L. Barbieri, MD, Medical
Care of the Pregnant Patient, 2nd edition. Rosene-Montella K, Keely EJ, Lee RV,
Barbour LA, eds. Philadelphia: American College of Physicians; 2007
Procedure Mean radiation
exposure to fetus
(mGy)
Comments
Head CT <0.01 Test of choice for SAH, subdural, epidural or
intraparenchymal hemorrhage
Spine CT <0.01
Chest CT 0.06
Abdominal CT 8
Chest X-ray <0.01
Sinus X-ray <1
Lumbar spine 1.7
Abdominal X-ray 1.4
Mammography <1 per breast Less sensitive in pregnancy
Cerebral angiography Depends on length on fluoroscopy
Pulmonary angiography Brachial approach : <0.5
Femoral approach : 2-3
Cardiac catheterization 5 Ioxaglate as IV contrast
reassuring risk profile in animal models
Cerebral MRI None Long-term data not yet
available; ideal for PRES, cerebral vein thrombosis,
pituitary, AVM
Other MRI None
Ultrasound None
Perfusion-ventilation scan V: 0.1-0.3 Q: 0.4-0.6
Cardiac radionuclide imaging ≤8
IVP Can be limited to 1.7
Otherwise 2.9-6.8
Concern about iodine
toxicity to developing fetal thyroid
Radioactive uptake scanning of the thyroid
Not indicated in pregnancy Discard milk for 24-48 hours
CanCOM Obstetric Medicine curriculum© 2010
Author: Annabelle Cumyn NOT for sale. NOT to be modified or used for research without the author’s written permission. Thank you. Page 37